ThrombophlebitisFormation of a venous clot depends on the

presence of of at least of one of Virchow’s triad factors

-venous stasis-injury to vessel wall-hypercoagulable state

SIGNS AND SYMPTOMSpain in the part of the body affected

skin redness or inflammation (not always present)

swelling (edema) of the extremities (ankle and foot).

CAUSES

Thrombophlebitis is related to a thrombus in the vein. Risk factors include prolonged sitting and disorders related to blood clotting

Specific disorders associated with thrombophlebitis include superficial thrombophlebitis (affects veins near the skin surface) and deep venous thrombosis (affects deeper, larger veins)

Clinical risk factors for deep vein thrombosisTrauma, travelHypercoagulable,

hormone replacementRecreational drugs(IV

drugs)Old (age >60y)Malignancy

Obesity, obstetricsSurgery, smokingImmobilizationBirth control, blood group

ASickness

PathophysiologyMost common cause of hereditary hemophilia is factor V

Leiden

Thrombi usually form at the venous cusps of deep veins where altered or static blood flow causes clot formation

Alternatively, clots form from intimal defects

Clots are composed from fibrin, red cells and platelets and cause partial/complete obstruction of vein

Pathophysiology

Postphlebitic syndrome (PPS) may develop after the resolution of a DVT

PPS is due valvular incompetence, persistent outflow obstruction and abnormal microcirculation.

Superficial ThrombophlebitisThrombosis can occur in any superficial vein

primarily the saphenous vein and its tributariesLocal pain, redness, and tenderness are characteristic

findings.Mild cases can be treated with warm compresses,

analgesia and elastic supportsSevere cases can be debilitating and should be

managed by bed rest, elevation of extremity, support stockings, and analgesia.

Antibiotics and anticoagulants are useful in septic thrombophlebitis

Deep Vein ThrombosisClinical exam is unreliable for detection or exclusion

of a DVTPain, redness, swelling, and warmth are present in

less than half the patients with confirmed DVT.Pain in calf with dorsiflexion of ankle with the leg

straight (Homan’s sign) is unreliable

Deep Vein Thrombosis the leg is white due to arterial spasm secondary to

massive iliofemoral thrombosis, often mistaken for arterial occlusion.

PPS can be difficult to differentiate from recurrent DVT due to pain, swelling and ulceration of the skin.

Up to to one third of the patients with DVT can develop PPS.

Deep Vein Thrombosis-DiagnosisAll patients with any signs or symptoms suggestive DVT

should undergo an objective diagnostic evaluationVenography was the historical “gold standard” for

detection of DVT with 100% sensitivity and specificity but it is invasive and can cause contrast-related reactions, phlebitis and DVT .

Axillary and Subclavian Vein thrombosis2-4% of DVTs occur in axillary or subclavian veinRisks include recent central venous catheters or

pacemakers, IV drug use, malignancy, hypercoagulable states and excessive or unusual exercise, chronic compression(cervical rib, scalene or web)

Treatment includes anticoagulation alone or preceded by thrombolysis.

Pelvic Vein ThrombosisUsually it’s an extension of a clot from the femoral

vein. An isolated pelvic vein thrombosis is rare and can be

a complication in the postpartum period, after pelvic surgery or trauma.

Septic pelvic vein thrombophlebitis is a life-threatening condition after post-partum endometritis and is usually diagnosed with CT or MRI.

COMPLICATIONSThe most serious complication occurs when the blood

clot dislodges, traveling through the heart and occluding the dense capillarynetwork of the lungs; this is a pulmonary embolism which can be potentially life threatening

TreatmentBed rest, leg elevation and elastic stockings are of

unproven benefit in the management of DVT.Aggressive anticoagulation will prevent extension of

the clot.Early ambulation after adequate anticoagulation is a

safe approachPrimary objective of treating DVT is the prevention of

pulmonary embolus

TreatmentMedications analgesics (pain medications)anticoagulants e.g warfarin or heparin to prevent new

clot formationthrombolytics to dissolve an existing clot such as

intravenous streptokinase.nonsteroidal anti-inflammatory medications (NSAIDS)

such as ibuprofen to reduce pain and inflammationantibiotics (if infection is present) selection will usually

depend with the causative agent.Support stockings and wraps to reduce discomfort

TreatmentIn pregnant pt who cannot have heparin, danaproid

should be used.

Warfarin is contraindicated in pregnancy, active bleeding, recent major surgery (thoracoabdominal, nervous system, spine, eye)

The patient may be advised to do the followingElevate the affected area to reduce swelling.Keep pressure off of the area to reduce pain and

decrease the risk of further damage.Apply moist heat to reduce inflammation and pain.Surgical removal, stripping, or bypass of the vein is rarely

needed but may be recommended in some situations.